Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellbridge Of Brighton during CMS and state inspections, most recent first.
A resident with a prosthetic joint infection and open knee wound did not have proper follow-up after an ID consult, and the facility relied on an unclear verbal report that there were no new orders. The AVS later showed Keflex was to continue long term, but the MAR showed the antibiotic had stopped earlier. A later outside nephrology visit also had no follow-up documentation, and staff could not confirm whether the appointment occurred or whether the AVS was obtained.
A resident admitted after femur fracture repair with a Foley and moderate pressure injury risk developed a worsening coccyx wound that progressed from redness and a small open area to an unstageable ulcer with eschar and slough. Staff documentation showed an incomplete admission skin check, delayed documentation of the second skin assessment, and a two-day delay in obtaining new wound treatment after the wound decline was identified. Interviews confirmed the skin assessment was not thorough and the RN forgot to document the findings.
Failure to maintain a grievance-based CNA assignment restriction: A cognitively intact resident with impaired mobility, a diabetic foot ulcer, and O2 needs reported that a CNA handled them roughly during repositioning and Hoyer lift transfers. Although the grievance was documented as resolved and the aide was supposed to be removed from all care, the CNA was still assigned to the resident’s hall/room and continued to document care on the resident’s TAR, requiring the resident to remind staff that the CNA was not to care for them.
A resident with advanced dementia and severe cognitive impairment was found with unexplained bruising on the chest and rib cage, which was not reported to the state agency, hospice provider, or legal representative as required. Staff observed and discussed the injuries but did not ensure proper follow-up or documentation, and the facility's abuse coordinator attributed the bruising to a transfer without confirming details or notifying the family.
A resident with advanced dementia and severe cognitive impairment was found with unexplained bruising on the chest and rib cage, which was not reported to the hospice provider or guardian. Staff failed to clearly document the injuries' locations, did not follow up after initial reports, and did not conduct a thorough investigation as required by facility policy. The abuse coordinator and NHA were unaware of the injuries until the survey, and there was no evidence of family notification or comprehensive staff interviews.
A resident with severe cognitive impairment developed an unstageable pressure ulcer that became infected due to the facility's failure to follow wound care recommendations. Despite having a low air loss mattress and a ROHO cushion, the resident's condition worsened, leading to hospital admission for surgical debridement and IV antibiotics. The facility's documentation showed inconsistencies, and the wound care clinic's recommendations for a group 3 air-fluidized bed were not pursued, contributing to the deterioration of the wound.
The facility failed to maintain sanitary conditions in the main kitchen and south satellite kitchen. Observations included unsealed food packages, soiled surfaces, and damaged equipment. The Culinary Specialist and Dietary Manager acknowledged these issues, but documentation for necessary repairs was not provided. The facility's policy and FDA Food Code require cleanliness and proper maintenance of food storage and preparation areas.
The facility failed to administer medications according to policy for two residents, with one receiving medications not prepared by the administering LPN and another receiving nasal medication incorrectly. Additionally, a resident's wound care was improperly documented, with treatments recorded as completed daily despite orders for every three days. The DON was unaware of these issues.
The facility failed to discard expired medications and ensure secure storage for three residents. An LPN administered expired medications without checking dates, and another LPN did the same with a Multivitamin. Expired medications were also found in the storage room. Additionally, a resident had discontinued eye drops left on their bed instead of being locked away. The DON confirmed these practices were against policy.
The facility failed to follow proper infection control practices for cleaning glucometers, as an LPN was observed using an alcohol prep pad instead of the required two disposable wipes after obtaining blood glucose levels from two residents. This practice did not align with the facility's policy or the manufacturer's instructions, which are designed to prevent the transmission of blood-borne pathogens. The DON acknowledged the issue but did not provide further explanation.
A resident with Parkinson's Disease experienced communication difficulties due to unclear speech, despite having intact cognition. Staff were not utilizing a guide with communication techniques created by an SLP, and these interventions were not included in the resident's care plan. The resident became tearful when not understood, and staff reported challenges in communication. The DON acknowledged that communication interventions should be in the care plan, but they were not.
A resident with obstructive sleep apnea did not have a physician order for their CPAP machine, despite needing assistance to use it at night. The resident expressed difficulty in receiving help from staff, and the DON acknowledged the need for a physician order, but no further action was documented.
A facility failed to maintain accurate medical records for a resident with severe cognitive impairment and pressure ulcers. Discrepancies in wound documentation were noted, with inconsistent labeling and numbering. Additionally, important wound care clinic consultation notes recommending a group 3 air-fluidized bed were not documented or communicated to the administrator. The DON acknowledged the inconsistencies but could not explain the lapses in obtaining consultation notes.
The facility failed to provide adequate supervision for a cognitively impaired, wheelchair-bound resident, resulting in an unwitnessed exit and fall with injury. Another resident, a high fall risk due to severe cognitive impairment and a recent femur fracture, experienced multiple falls without appropriate interventions. The facility's outdated policies and insufficient investigations contributed to these deficiencies.
The facility failed to administer and document scheduled medications for ten residents due to an EMR outage. Staff interviews revealed confusion and conflicting information about whether medications were given. The facility's policy on EMR disruptions was not effectively implemented, and medications were not documented post-outage as required.
The facility failed to document medication administration for ten residents due to an EMR outage. Staff provided conflicting accounts of whether medications were given, and the downtime policy was not effectively communicated or followed. This led to incomplete medical records and concerns about medication management.
Two residents experienced inadequate pain management at the facility. One resident, with multiple medical conditions, did not receive timely pain medication after a fall, leading to severe unrelieved pain. The care plan was not updated, and there was no evidence of follow-up care. Another resident, post-joint replacement surgery, did not receive scheduled doses of Norco, and the facility could not locate the narcotic log. Both residents reported feeling their pain was not adequately managed.
A facility failed to maintain accurate records for the administration of Norco, a controlled substance, to a resident following joint replacement surgery. The resident reported increased pain, suggesting missed doses, and the facility could not locate the narcotic log for the specified doses. The DON confirmed that MAR audits were not conducted on a scheduled basis, and no explanation was provided for the missing documentation.
A resident alleged sexual abuse by a male staff member, but the facility failed to report these allegations to the State Agency. Despite the resident's moderately impaired cognition, the facility did not take the allegations seriously, and no police involvement was initiated. The facility's staff, including LPNs and the Administrator, did not follow the protocol for reporting abuse, resulting in a deficiency in compliance with abuse reporting regulations.
Failure to Follow Up on Outside Consultations and Antibiotic Orders
Penalty
Summary
The facility failed to follow up on an outside Infectious Disease consultation for a resident admitted after hospitalization for a prosthetic joint infection with an open wound over the left patella. Family reported that the resident was supposed to receive long-term Keflex through August 2026, but the facility did not have the After Visit Summary from the 2/25/26 ID visit and relied on a verbal statement from an unknown person at the ID office that there were no new orders. The nursing note documented that the resident returned from the appointment with no paperwork, and the note did not identify the position of the person contacted at the clinic. The resident’s MAR showed Keflex 1000 mg was last administered on 3/11/26. The ID clinic note was not received by the facility until 4/21/26, and it documented that Cephalexin was to continue, then decrease to 500 mg twice daily, with an end date of 8/17/26. The DON acknowledged the facility failed to ensure outside appointment consultations were followed for this resident. A later audit also found another outside appointment with Nephrology had no follow-up documentation in the chart, and staff interviews showed no one could confirm whether the appointment occurred or whether the AVS had been retrieved.
Failure to Provide Timely Pressure Ulcer Care and Documentation
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with a recent right femoral fracture repair, postoperative urinary retention, and a Foley catheter. On admission, the resident had a foam dressing to the coccyx area and a Braden Score of 13, indicating moderate risk for pressure sore development. The admission skin check documented a cluster of raised scab markings on the lower backside with no open areas present, but the record also noted scant stool under the dressing. A later skin check documented redness to the coccyx with a small open area and non-blanchable skin, and a new skin issue was entered as moisture associated skin damage with a wound acquired in-house. The wound was documented as deteriorating, and the Braden Score later dropped to 7, indicating very high risk for worsening pressure ulcer development. On a Saturday, nursing documented that the coccyx wound had declined and a message was sent to management to assess it on Monday and change the wound care order, with no new treatment obtained or implemented for two days after the worsening was identified. When the physician evaluated the resident, the sacral wound was described as unstageable with eschar, yellow slough, surrounding erythema, and MASD, and wound care orders were updated. During record review, the care plan showed an unstageable coccyx pressure ulcer dated earlier than the physician diagnosis, which the DON later acknowledged was entered by Corporate Clinical on the same day as the physician assessment. Staff interviews also confirmed the initial skin assessment had not been thorough, and the RN who completed the second skin check stated they forgot to document the findings and had assessed the area quickly while the resident was in significant pain.
Failure to Maintain Grievance-Based CNA Assignment Restriction
Penalty
Summary
The facility failed to support continuity of a previously resolved grievance for a resident who was cognitively intact, had impaired mobility related to a recent hospitalization for respiratory and congestive heart failure, required wound care for a diabetic right foot ulcer, and used supplemental oxygen. The resident reported that CNA B hurt them when repositioning them or placing them into a Hoyer lift and said the concern had already been brought to staff, with the resident told CNA B would no longer be assigned to care for them. The resident also stated they still had to remind staff that CNA B was not to care for them when the CNA was seen in the room. Record review showed the grievance form documented the resident’s complaint about transfer discomfort with one aide, identified as CNA B, and the investigation summary stated the aide was removed from all care. However, CNA B’s documentation still appeared on the resident’s Eating TAR on multiple dates after the grievance was resolved. Interviews confirmed CNA B had been scheduled to the resident’s hall and room because of the roommate arrangement, and CNA B acknowledged they were still assigned to the room and charted on the resident’s TAR based on information reported by another CNA. The scheduler also confirmed CNA B was assigned to the entire hall and that room assignments were handled through CNA collaboration and swapping, despite the prior grievance.
Failure to Timely Report Injuries of Unknown Origin and Notify Authorities
Penalty
Summary
The facility failed to report an alleged violation to the state agency regarding injuries of unknown origin for one resident with advanced Alzheimer’s dementia, severe cognitive impairment, and who was nonverbal and bed/chair bound. The resident was observed with yellow bruising on the sternal chest wall and dark red-purple bruising on the right rib cage, which were not consistent with the care provided. These injuries were not reported to the hospice provider or the resident’s legal representative. Staff interviews revealed that the bruising was noticed by both a registered nurse and a certified nurse assistant, but there was confusion and lack of follow-up regarding who should report the incident. The facility’s policy required immediate reporting of such incidents to supervisors and the administrator, as well as prompt notification of the attending physician and legal representative, but these steps were not followed. Further review showed that the abuse coordinator documented a change in condition, attributing the rib bruising to a two-person transfer without confirming the details or notifying the family. There was no documentation explaining the cause of the sternal bruising or evidence that the family was informed at the time of the incident. The nursing home administrator, who also served as the abuse coordinator, confirmed that the injuries would have been formally investigated and reported to the state agency if they had been aware, but the issue only came to their attention during the survey.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into injuries of unknown origin for one resident with advanced Alzheimer’s dementia, severe cognitive impairment, and who was nonverbal and bed/chair bound. The resident was observed with yellow bruising on the sternal chest wall and dark red-purple bruising on the rib cage, which were not consistent with the care provided and were not reported to the hospice provider or guardian. Photographs of the injuries were taken, but the anatomical locations were unclear, and staff could not consistently recall or identify the locations. Documentation was incomplete, with no clear record of how the injuries occurred, and there was no evidence that the family was notified about the bruising. Interviews revealed that staff did not follow up on the bruising after it was initially reported, and the abuse coordinator could not confirm who reported the incident or provide documentation of a thorough investigation, including staff interviews or education. The facility’s policy required immediate reporting, assessment, and comprehensive investigation of such incidents, including interviews and written statements from witnesses, but these steps were not followed. The nursing home administrator, who also served as the abuse coordinator, was unaware of the injuries until the survey and confirmed that a formal investigation and reporting to the state agency would have occurred had they been informed.
Failure to Follow Wound Care Recommendations Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure accurate assessments and coordination of care for a resident with pressure ulcers, leading to a significant deterioration of the resident's condition. The resident, who had severe cognitive impairment and required substantial assistance for mobility, was observed with a low air loss mattress and a ROHO cushion. Despite these interventions, the resident developed an unstageable pressure ulcer that became infected, necessitating hospital admission for surgical debridement and intravenous antibiotics. The facility's documentation showed inconsistencies in wound assessments, with discrepancies in the staging and location of the wounds. The wound care clinic's recommendations for the resident were not followed, including the use of a group 3 air-fluidized bed for optimal offloading. The clinic's consultation notes indicated that the resident's wounds had worsened due to suboptimal offloading and inconsistent adherence to directives. The facility's staff failed to procure the recommended bed, and the resident's preference for lying on their back further contributed to the deterioration of the wound. The wound care clinic doctor disagreed with the facility's classification of the ulcer as a Kennedy terminal ulcer, noting that the resident was not imminently dying but was at high risk for sepsis and death without urgent intervention. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's wound care. The Director of Nursing was unaware of the wound care clinic's recommendations, and the attending physician had not seen the resident since early July. The nurse practitioner deferred to the wound care clinic for monitoring the wounds, and the facility's policy on pressure ulcer prevention was not effectively implemented. The failure to follow recommended interventions and accurately document the resident's condition resulted in a serious health deficiency.
Sanitation Deficiencies in Kitchen and Satellite Kitchen
Penalty
Summary
The facility failed to maintain the main kitchen and the south satellite kitchen in a sanitary manner, as observed during a survey. In the dry food storage room, a package of sweet cornbread muffin mix was found unsealed and exposed to air. Similarly, in the walk-in refrigerator, a large package of fresh carrots was not sealed and exposed to air. In the south kitchenette, several sanitation issues were identified, including dried debris on countertops, soiled glass enclosures, and missing portions of the seal connecting the glass to the countertop. The walls were stained with dried food debris, and the flooring under the sink was covered with thick, black debris. Additionally, the microwave was heavily soiled with food particles, and the laminate bottom shelf under the steam table was chipped, worn, and swollen from water damage, with trays and food equipment stored directly on it. The Culinary Specialist and Dietary Manager confirmed these concerns and indicated that a closing night checklist was supposed to ensure cleanliness after every shift. However, documentation of an invoice for repairs needed for the satellite kitchens was not provided when requested. The facility's policy on kitchen sanitation requires all utensils, counters, shelves, and equipment to be kept clean and in good repair, free from breaks, corrosion, and other defects that may affect proper cleaning. The FDA Food Code also mandates that food be stored in a clean, dry location and that physical facilities be cleaned as often as necessary to prevent soil accumulation.
Medication Administration and Wound Care Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards and facility policy for two residents. One resident was given medications by an LPN who did not prepare them, as the medications were found in a clear cup in the medication cabinet without proper labeling. The LPN administered the medications without verifying them according to the facility's policy, which requires checking the label three times to ensure the right resident, medication, dosage, time, and method of administration. Another resident received nasal medication incorrectly. The LPN administering the medication did not follow the facility's protocol, which requires closing the opposite nostril while spraying the medication. The Director of Nursing confirmed that the LPN should have followed the correct procedure, but no further explanation or documentation was provided by the end of the survey. Additionally, the facility failed to provide proper wound care treatment and documentation for a resident with a non-pressure wound. The resident's treatment was documented as being completed daily, despite the physician's order specifying treatment every three days. The Unit Manager removed the resident's bandage with bare hands and confirmed the wound was healed, but could not explain the discrepancy in documentation. The Director of Nursing was unaware of the issue and reported that random audits had not identified it as a problem.
Expired and Improperly Stored Medications
Penalty
Summary
The facility failed to ensure that expired medications were discarded and medications were stored securely for three residents. On October 14, 2024, an LPN was observed administering expired medications, including Docusate Sodium and a Multivitamin, to a resident without checking the expiration dates. Another LPN also administered an expired Multivitamin to a different resident. Both LPNs acknowledged the oversight and removed the expired medications from the residents' medication cabinets. Additionally, an inspection of the medication storage room revealed several expired medications, including Vitamin C, Aspirin, and Vitamin B6, which were not removed from inventory as per the facility's policy. Furthermore, a resident was found with a bottle of Systane eye drops on their bed, which should have been locked in the medicine cabinet. The eye drops had been discontinued on September 27, 2024, but were not removed from the resident's possession. The Director of Nursing confirmed that medications should not be left on a resident's bed and acknowledged that the discontinued medication should have been removed from the cabinet. The facility staff did not adhere to the protocol outlined in their medication storage policy, leading to these deficiencies.
Improper Infection Control Practices for Glucometer Cleaning
Penalty
Summary
The facility failed to maintain proper infection control practices regarding the cleaning and disinfecting of glucometers, as observed during the medication administration task for two residents. On the specified date, an LPN was seen using an alcohol prep pad to clean the glucometer after obtaining blood glucose levels from two residents. This practice was not in accordance with the facility's policy or the manufacturer's instructions, which require the use of two disposable wipes for cleaning and disinfecting the glucometer after each use. The facility's policy, revised in April 2012, and the manufacturer's booklet both emphasize the importance of following specific cleaning and disinfecting procedures to prevent the transmission of blood-borne pathogens. The manufacturer's instructions explicitly state that an alcohol prep pad is not an approved cleaning or disinfecting agent. Despite this, the Director of Nursing initially indicated that alcohol swabs could be used after each use of the glucometer, which contradicts the established guidelines. The DON acknowledged the concern but did not provide further explanation.
Failure to Implement Communication Interventions for Resident with Parkinson's
Penalty
Summary
The facility failed to ensure effective communication interventions for a resident with Parkinson's Disease, who had difficulty speaking clearly. Despite the resident's intact cognition and ability to understand others, staff reported challenges in understanding her speech. Observations revealed that the resident became tearful when not understood, and attempts to communicate through writing were illegible. A Speech Language Pathologist (SLP) had been working with the resident since January 2024 and had created a laminated guide with communication techniques for staff and the resident. However, staff were not utilizing these techniques, and the guide was not incorporated into the resident's care plan. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), indicated a lack of awareness and implementation of the SLP's recommendations. The resident's care plan, initiated in January 2024 and revised in May 2024, did not include specific interventions recommended by the SLP, such as referring to the guide or using specific communication techniques. The DON acknowledged that communication interventions should be included in the care plan and Kardex, but they were not. This oversight resulted in the resident's communication needs not being adequately addressed, leading to distress and ineffective communication.
Failure to Implement CPAP Orders for Resident
Penalty
Summary
The facility failed to ensure that a CPAP machine was properly ordered and utilized for a resident with obstructive sleep apnea. The resident, who was admitted with diagnoses including acute pyelonephritis, Parkinson's, and obstructive sleep apnea, expressed difficulty in receiving assistance to use their CPAP machine at night. Despite the resident's moderately impaired cognition and need for extensive assistance with activities of daily living, there were no physician orders for the CPAP machine, which was noted in the hospital referral paperwork. Observations revealed that the resident had to request staff assistance to use the CPAP machine, which was not consistently provided. The Director of Nursing acknowledged that a physician order should be in place for the CPAP machine, but no further documentation or corrective action was provided by the end of the survey. This lack of proper documentation and implementation of physician orders for the CPAP machine constitutes a deficiency in the facility's respiratory care for the resident.
Inaccurate Medical Records and Documentation Lapses
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as R18, who was admitted with diagnoses including acute and chronic respiratory failure, cervical disc disorder, and atrial fibrillation. The Minimum Data Set (MDS) assessment indicated that R18 had severely impaired cognition and required substantial assistance for mobility. The resident also had two facility-acquired Stage 2 pressure ulcers. However, discrepancies were found in the documentation of R18's wounds, with inconsistent labeling and numbering of the same wound across different evaluations. The Director of Nursing (DON) acknowledged these inconsistencies but could not provide a satisfactory explanation for them. Additionally, the facility failed to document consultation notes from the wound care clinic, which included important treatment recommendations for R18's wounds. The consultation notes revealed that the resident's wounds had worsened and recommended the use of a group 3 air-fluidized bed for optimal offloading. However, these recommendations were not communicated to the facility's administrator, and the consultation notes were not requested until after the surveyor's inquiry. The DON had no explanation for why the consultation notes were not obtained earlier, indicating a lapse in the facility's process for maintaining accurate and complete medical records.
Inadequate Supervision and Fall Risk Management
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired, wheelchair-bound resident, resulting in an unwitnessed exit from the facility and a fall with injury. The resident, who had a history of falls and moderate cognitive impairment, was found outside the facility in a secluded area of the parking lot by a visitor. The resident reported severe pain following the fall, and there was no evidence of a follow-up evaluation by a physician or diagnostic tests ordered despite the nature of the incident. The facility's investigation into the incident was inadequate, with no root cause analysis conducted, and the resident's guardian was not notified of the incident. Another resident, who was a high fall risk due to severe cognitive impairment and a recent femur fracture, experienced multiple falls after admission to the facility. The facility failed to provide appropriate interventions and supervision, with the root cause analysis for the falls being insufficiently addressed. The resident had several falls related to incontinence episodes and attempts to get out of bed, yet the interventions provided were not specific or adequate to prevent further falls. The facility's policies on elopement and fall risk management were outdated and did not adequately address the identification and assessment of at-risk residents or the provision of supervision. The facility's failure to conduct thorough investigations and implement effective interventions contributed to the deficiencies observed in the care of these residents.
Failure to Document Medication Administration During EMR Outage
Penalty
Summary
The facility failed to administer and document scheduled medications according to professional standards for ten out of fifteen residents reviewed. The Medication Administration Records (MAR) for these residents showed multiple instances where medications were not documented as administered. This included various medications such as GenTeal Tears, Senna, Cyclosporine Emulsion, Eliquis, Levothyroxine, and others, which were scheduled to be given at specific times but lacked documentation of administration. Interviews with staff revealed inconsistencies and confusion regarding the administration and documentation of medications during a reported Electronic Medical Record (EMR) system outage. The Director of Nursing (DON) and Regional Nurse A provided conflicting information about whether the medications were administered. LPN J, who was responsible for administering medications to several residents, stated that medications were given but not documented due to the EMR outage. However, there was no follow-up to ensure these medications were documented once the system was operational again. The facility's policy on disruptions in the EMR system was not effectively implemented during the outage. The policy required a backup plan for disruptions longer than two hours, but staff interviews indicated a lack of awareness and execution of this plan. The DON acknowledged that the medications were not documented post-outage, and the facility's policy on medication administration required immediate recording of administered medications, which was not adhered to in this instance.
Medication Administration Documentation Failure
Penalty
Summary
The facility failed to maintain complete and accurate medical records for ten residents regarding medication administration. The Medication Administration Records (MAR) for these residents showed that several scheduled medications were not documented as being administered over the course of a specific night and morning. This included a range of medications such as ophthalmic gels, oral tablets, and subcutaneous solutions, which were not recorded in the electronic medical records (EMR) system. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Practical Nurses (LPNs), revealed inconsistencies and confusion regarding the administration and documentation of medications during an EMR system outage. The DON and Regional Nurse A provided conflicting information about whether the medications were administered. LPN J reported administering the medications but was unable to document them due to the EMR outage, while LPN F claimed to have documented all medications despite the outage. The facility's downtime policy was not effectively communicated or followed, leading to a lack of documentation. The facility's policy on medication administration requires that medications be documented immediately after administration, which was not adhered to in this case. The policy for handling disruptions in the EMR system was updated after the incident, indicating a lack of preparedness for such outages at the time of the deficiency. The failure to document medication administration accurately and timely raises concerns about the facility's ability to ensure proper medication management and resident care.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, resulting in unrelieved pain and emotional distress. Resident R903, who had multiple medical conditions including schizophrenia, anxiety disorder, COPD, Parkinson's disease, and end-stage renal disease, experienced severe pain following a fall outside the facility. Despite reporting a pain level of 8/10 after the fall, R903 did not receive any pain medication until several days later. The facility's records showed a lack of timely pain assessments and follow-up care, with no pain medication administered from the time of the fall until 8/26/24, despite the resident's ongoing complaints of severe pain. Additionally, R903's care plan was not updated to reflect their recent readmission and fall, and there was no evidence of physician or mid-level provider visits following the incident. The Director of Nursing confirmed the absence of pain assessments and medication administration after the fall and acknowledged that non-pharmacologic interventions were not attempted. The facility's failure to manage R903's pain effectively led to the resident experiencing unrelieved pain and frustration. Resident R916 also experienced inadequate pain management following joint replacement surgery. The facility's records showed that scheduled doses of Norco, a narcotic pain medication, were not documented as administered on 8/7/24. R916 reported waking up with increased pain, indicating that they did not receive the scheduled doses. The facility was unable to locate the narcotic log for the missing doses, and R916 expressed feeling that their pain was not believed or adequately managed by the staff.
Failure to Document Administration of Controlled Substances
Penalty
Summary
The facility failed to ensure accurate record-keeping for the administration of controlled substances, specifically for a resident identified as R916. The resident was admitted with diagnoses including muscle weakness, aftercare following joint replacement surgery, and difficulty walking. The Minimum Data Set (MDS) assessment indicated that the resident had intact cognition. The Medication Administration Record (MAR) for R916 showed an order for Norco, a narcotic pain medication, to be administered every six hours. However, there was no documentation for the midnight and 6 AM doses on a specific date. Upon request, the facility was unable to provide the narcotic log for the specified doses, and the Director of Nursing (DON) confirmed that the log could not be located. During an interview, the resident reported experiencing increased pain in the morning, suggesting that the scheduled doses were not administered. The resident also expressed that their pain was not adequately managed and felt that the staff did not believe the level of pain they reported. The DON stated that audits of the MARs were conducted periodically but not on a scheduled basis, and no explanation was provided for the missing documentation or the narcotic log.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report multiple allegations of abuse and mistreatment to the Abuse Coordinator and the State Agency for a resident who alleged being sexually abused by a male staff member. The resident, who had moderately impaired cognition and no documented behaviors, reported two incidents of sexual abuse and one incident of being threatened by the same staff member. Despite the resident's allegations, the facility did not report these incidents to the appropriate authorities. Interviews and record reviews revealed that the resident had expressed concerns about being manhandled and threatened by a male aide. The resident had reported these incidents to a staff member, but the allegations were not taken seriously, and no police involvement was initiated. The facility's staff, including LPNs and the Administrator, failed to follow the protocol for reporting abuse allegations, resulting in a lack of proper investigation and notification to the State Agency. The facility's policy required immediate reporting of abuse allegations, but the Administrator did not report the incidents to the State Agency, as she determined there was no abuse after speaking with the resident's roommate. The Administrator and other staff members were unaware of the facility's Abuse Coordinator, leading to confusion and miscommunication regarding the handling of abuse allegations. This failure to report and investigate the allegations properly resulted in a deficiency in the facility's compliance with abuse reporting regulations.
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Illustrative
What surveyors actually found near you
We read the 310 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Howell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caretel Inns Of Brighton | 4.4 mi | ★★★★★ | 6 | 0 |
| Medilodge Of Howell | 4.8 mi | ★★★★★ | 19 | 0 |
| The Willows At Howell | 6.6 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Livingston | 7.8 mi | ★★★★★ | 12 | 0 |
| West Hickory Haven | 9 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.